The Longevity Juggle: 10 takeaways from Peter Attia’s Outlive

LF38 | The world's leading longevity doctor provides an accessible handbook for those bamboozled by information overload

Credit: MidJourney (prompt: peter attia as a juggler on a unicycle, juggling pills, babies, dumbells, kale and a therapist couch)

Peter Attia’s Outlive is the very definition of a magnum opus. This celebrated longevity doctor and podcaster has been writing this tome for years; he was even fired by his publisher a couple of years ago for failing to deliver. Funnily enough, I reached out to him a few years ago for a client project and was told, politely, that he’s too busy working on his book. But it’s now out and it’s the #1 NYTimes Best Seller for a reason - it’s a fact filled, clear-eyed, accessible handbook for longevity that helps people understand the why, not just the what.

This is a book that’s going to be worth re-reading as it’s so information dense, but based on my first read, here’s ten things that jumped out.

1. Emotional health eats physical health for breakfast. You’re likely familiar with the idea that healthspan (the days lived in good health) is more important that lifespan (the total days lived). The last chapter makes clear the importance of emotional health in the healthspan; as Esther Perel told him, what’s the point in living a long life if you’re unhappy? Peter’s honest accounts of his anger issues, relationship stress and mis-allocated priorities (e.g. carrying on a business trip for 10 days after his infant son almost died) provide a stark reminder that you can be obsessing about the wrong goal until it’s too late.

2. Objectives, Strategy, Tactics. As a former consultant, he spends quite a bit of time on strategy - how you are going to go about reaching your overall goal. The tactics are the things we’re most familiar with - diet, exercise, sleep, emotional health and pills / supplements. But if you don’t have a strategic framework for your life - such as the Centenarian Olympics below, you’ll end up just doing whackamole with the latest fads exercises and diets. Figure out what your ideal long life looks like first, then pick the tactics to deliver it.

3. Get fit for your Centenarian Olympics. I’ve written about this powerful idea before. Peter suggests you identify what you want to be doing at 100, then work backwards and translate it to today’s actions. He focuses on the physical aspects (though I’d argue the financial ones are also important, see below). Is it lifting up your grand children (or great grandchildren)? That’s effectively a goblet squat of 15kg - not much for a 40 year old, but to do that at 100, the 40 year old needs to be able to do 2 or 3 times that today.

4. Start early as possible to avoid the Four Horsemen. Statistically, what kills most people is the Big 4; not the accounting firms, but heart disease, cancer, neurological disease (e.g. dementia) and diabetes / metabolism. While deaths from heart disease have declined two thirds in the past fifty years, little progress has been made with the other three. Today’s healthcare business and disease risk models are not fit for purpose, if purpose is a long healthy life free of disease. We need to be calculating your 50 year risk of cardiac disease, not your 5 year one.

5. Hammer ApoB for heart health. Heart disease is very personal for Peter - several of this uncles died early from it, so it’s his number one concern - especially since seeing evidence of calcium on a heart scan in his 30s. There is some scepticism about Big Pharma - coincidentally Peter’s alma mater McKinsey was fined several hundred million for its role in exacerbating the opiod epidemic. But Peter is a big believer in statins and PSK9 inhibitors to improve blood lipid profile in particular ApoB, which he implicates as the primary cause of cardiovascular disease.

6. Don’t stress over diet, but do reduce calories. Attia used to adhere strictly to a keto diet - and was in the ‘food is medicine camp’, but is now less extreme. He spend more time complaining about the internecine warfare among the various diet advocates (paleo vs keto vs vegan vs carnivore etc) than in the substance of what to eat. He says focus mostly on limiting the total calories, but has moved away from fasting and intermittent fasting, worrying about its effects on muscle loss. [Note: Given that insulin resistance is the red thread connecting all these four horsemen, the reduction in importance of diet was surprising to me.]

7. Sleep for health. In his 30s, as a hard charging doctor, Peter would regularly work for 24 hours straight, at one stage went to work on a Monday morning, returning on Wednesday evening, all the while holding his patients’ lives in his hands. He admits being reluctant to put maximums on junior doctors’ hours, but now sees that as a mistake. He thinks many of his own challenges with health in his 30s were the result of poor sleep rather than diet or exercise.

8. Exercise is the killer app. Peter’s changed his thinking about exercise and muscle mass - now ranking these above diet, based on strong evidence that exercise is ‘dose dependent’ for longevity - the more you do of it, the longer your healthspan (days lived in good health) and also your lifespan. Did you know your grip strength is an excellent marker for dementia and overall mortality risk? Grab that iron and start lifting weights.

9. A missing industry for the healthy not the sick. The US has a very robust sick care industry, in which physicians, hospitals and drug companies mostly ignore people on the path of disease (‘there are no reimbursement codes…’), waiting until they’re sick. A recurrent theme throughout the book is the need to ‘catch the people before they fall’ rather than trying to pick up the pieces at the bottom. There’s not really a longevity industry per se - the word itself extends of biohackers and snake-oil charlatans, with ‘wellness’ not taken seriously by doctors. Why would it, when the act of wellness would delay the arrival of a client? I imagine a Virtual Peter, providing personalised advice for people looking to stay healthy for longer (and not in a position to be a concierge client) would be successful, and I suspect he’s working on something like this. We need 100x more.

10. What’s missing? How to pay for longevity. Attia is an incredibly hard working, successful celebrated, celebrity doctor, and I’ve heard it’s $140k a year to be a concierge client of his, so once can assume he’s not short of a bob or two. The reality for most people looking forward to their later years is that a big part of quality of life is money. Emotional health is more than relationships, it’s also about not being stressed that you’ll be homeless or can’t afford medical bills (the cause of one third of US bankruptcies). We need to see longevity as part of an integrated system - how to be happy and how to pay for it if we’re lucky enough to get there.